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(call sign) PERSONNEL STATEMENT FEDERAL AVIATION ADMINISTRATION NEW YORK AIR ROUTE TRAFFIC CONTROL CENTER ACTION: Complete in accordance with FAA Order 8020. 1 IB, Aircraft Accident and Incident Notification, Investigation, and Reporting, paragraph 75, Personnel Statements. BACKGROUND: Much of the information concerning the circumstances surrounding this accident/incident can be retrieved via some type of recorded data source. However, some of the facts concerning what you saw and what you did may not have been completely captured. The purpose of this statement is to provide any facts within your personal knowledge that you believe will provide a more complete understanding of the circumstances surrounding this accident/incident Therefore, speculations, hearsay opinions, conclusions, and/or other extraneous data are not to be included in this statement Additionally, this statement may be released to the public through FOIA or litigation activities including pretrial discovery, depositions, and actual court testimony. INSTRUCTIONS: This statement is to be PRINTED and signed by you. Statement times and dates shall correspond with SISO. Your signature below certifies the accuracy of this statenratr-Jh will neither be edited nor typed, and, once signed, will constitute your original statement . (fry , / , IV f „ , \

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This statement concerns the accident/incident involvi

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by the FAA at me New York ARTCC, Ronkonkoma. New Yoifc position from

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of my knowledge and recollection, the above statement is correct

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